Anaemia Prevalence and Associated Factors among Women ...

International Journal of Medicine and Medical Sciences, ISSN:2051-5731, Vol.46, Issue.4

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Anaemia Prevalence and Associated Factors among Women Attending Antenatal Clinics in SouthWestern Ebonyi State, Nigeria Njoku Ivoke Parasitology and Public Health Research Unit, Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Joseph E Eyo Animal and Biomedical Physiology Research Unit, Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Obinna N Ivoke Department of Pathology, Ebonyi State University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria Email:[email protected]

Christopher D Nwani Molecular Biology and Biotechnology Division, Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Elijah C Odii Animal and Biomedical Physiology Research Unit, Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Chinweike N Asogwa Animal and Biomedical Physiology Research Unit, Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Felicia N Ekeh Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email: [email protected]

Chinedu I Atama Department of Zoology and Environmental Biology, University of Nigeria, Nsukka, Enugu State, Nigeria Email:[email protected]

ABSTRACT A multi-centre cross-sectional study was conducted between July 2012 and February 2013 to assess anaemia prevalence and associated factors among pregnant women attending three antenatal clinics in malaria endemic southwestern Ebonyi State, Nigeria. Haemoglobin (Hb) levels were determined using the Haemocue haemaglobinometer detecting system for 660 of the 702 eligible women, while their obstetrics and socioeconomic information were obtained using close-ended structured questionnaire. Mean age of the participants was 24.9 ± 6.1 years (range, 18 – 47 years); mean number of previous pregnancies was 4.7 ± 1.2 per woman (range, 1 – 12). Overall prevalence of anaemia during pregnancy (Hb ≤ 11 g per decilitre) was 60.0% (95% confidence interval (CI): 58-62). Prevalence of mild (10 g /dl ≤ Hb < 11 g /dl), moderate (7 g /dl ≤ Hb < 9 g/dl), and severe (Hb < 7 g /dl) anaemia was 56.8%, 37.9% and 5.3% respectively. Over 90% of the total anaemic women had Hb levels below the benchmark for pregnant women (11 g /dl). Multivariate analysis showed that anaemia in pregnancy was significantly and independently associated with low socio-economic status, advanced age of gestation and increasing number of previous pregnancies. The result is discussed in relation to the need for increased awareness campaign of the

associated predisposing factors of anaemia in pregnancy at the antenatal clinics levels.

Keywords– Anaemia, haemoglobin, pregnancy, trimester

1. INTRODUCTION Anaemia, defined by the World Health Organization (WHO) as a haemoglobin (Hb) level of < 12g/dl in adult non-pregnant women, occurs in 40-80% of pregnant women in Africa [1]. Anaemia is one of the world‟s leading causes of disability and constitutes a major global public health problem [2]. It is estimated that anaemia occurs in 42% of all women in the world and 52% of pregnant women in developing countries compared with 23% in the developed economies of the world [2]. It has further been estimated that anaemia accounts for 3.7% and 12.8% of maternal deaths during pregnancy and childbirth in Africa and Asia, respectively [3] and has been associated with low neonatal birth weight [4,5]. The prevalence of anaemia in pregnancy varies considerably because of differences in socio-economic conditions, life-styles and health-seeking behaviours across varying cultural settings. Anaemia in pregnancy is usually multi-factorial in origin and although malaria is an important contributor, nutritional deficiencies (iron and

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folic acid, other infectious parasitic diseases (hookworm, schistosomiasis, acquired immunodeficiency syndrome) and genetic red blood cell disorders, that is, haemoglobinopathies (sickle cell and thalassaemias) are other significant contributory factors [6-8]. The high prevalence of deficiencies of iron and other micronutrients during pregnancy among women of developing countries has been a source of considerable concern and maternal anaemia continues to cause perinatal morbidity and mortality in affected populations [9]. Due to poor nutritional intake, menstrual blood loss, recurrent parasitic infections and repeated pregnancies, women in many developing countries are usually in a state of precarious iron imbalance exhibited by iron and folate deficiencies during the reproductive years [10]. Currently, there is a dearth of published data on the haematological profile of pregnant women of varying obstetrics and demographic backgrounds living in the zone of perennial malaria transmission of southwestern Ebonyi State, Nigeria. The objectives of our study were to evaluate the extent of anaemia, and to assess its associated factors among pregnant women attending antenatal clinics (ANC) in the study communities. Given the public health importance of anaemia in pregnancy, data derived from the study could provide baseline information which would be incorporated in effective planning of antenatal intervention strategies for controlling anaemia during pregnancy in rural settings.

2. MATERIALS AND METHODS 2.1. Study Sites The multi-centre, hospital-based study was conducted between July 2012 and February 2013 in two Local Government Areas (LGAs) of Ebonyi State namely: Ohaozara and Onicha in south-western Ebonyi State. The two LGAs were selected for the study because of the presences of health facilities and high rates of maternal mortalities recorded during delivery in their hospitals. Three antenatal clinics were studied, two in Ohaozara LGA and one in Onicha LGA. Ohaozara LGA lies between latitudes 6°00', 6°20' N and longitudes 8°05', 8°25' E, whereas Onicha is located between the coordinates 6°20', 6°27' N and 8°05', 8°45' E [11]. The vegetation is typical of the guinea-savannah mosaic pattern of sparsely wooded, undulating terrain punctuated by gently rolling rocky hills adjourning swampy valleys. Two annual climatic cycles of short, hot dry season (November-March) and longer rainy period (AprilOctober) are experienced. Mean annual rainfall is 150 mm, mean annual relative humidity 70 ± 4%, mean daily minimum air temperature range (18-23°C) and minimum daily maximum air temperature range (29-35°C) [11]. The population which is basically rural and agrarian is scattered in village-based settlements where large scale farming of yam, rice, cassava and cocoyam constitute the dominant occupation. Health-care was provided by three government-owned general hospitals each with antenatal clinics located at Okposi, Onicha and Uburu autonomous

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communities, a few private health centres, and a large network of traditional practitioners.

2.2. Study Design and Population Multi-centre cross-sectional survey of anaemia among pregnant women attending three antenatal clinics (Okposi, Onicha and Uburu) was adopted for the study. Prior to the commencement of the study, ethical clearance and advocacy were sought from the hospitals management boards, while the study protocol was endorsed by the State Ministry of Health (MOH). Study participants consisted of 952 pregnant women who lived in the study communities and were attending ante-natal clinics (ANC) at any one of the three study sites. Inclusion criteria for participation were age ≥18 years, gestation age ≥16 and 35 weeks. All prospective participants were offered pretest counselling in vernacular language by a trained female health worker who also explained to the women the aim of the study and the process of obtaining blood samples for haematological studies [12]. After obtaining a non-coercive informed verbal consent from each of the women who agreed to participate, baseline information on demographic, socioeconomic, obstetric and medical history were collected using close-ended structured questionnaire.

2.3. Data Collection and Analysis Each participant‟s conjunctiva was assessed for pallor and the haemoglobin (Hb) level was determined using a portable Haemocue haemoglobinometer detecting system (Haemocue, Angelholm, Sweden). Anaemia in pregnancy was defined as an Hb level < 11g/dl, in accordance with WHO guidelines [13] and differentiated into three categories as „mild‟ (10 g/dl ≤ Hb < 11 g/dl), „moderate‟ (7 g/dl ≤ Hb < 10 g/dl), or „severe‟ (Hb < 7 g/dl). Socioeconomic status was classified by a scoring system taking into account the type of construction material used in the houses (mud/cement wall), consumer goods (television, motor cycle, motor car). Estimates were presented with their 95% confidence interval; level of statistical significance was fixed at p ≤ 0.05. Variables found to be associated with anaemia by univariate analysis (χ2 test or variance analysis as appropriate) were entered into a logistic regression model to identify risk factors for anaemia.

3. RESULTS During the eight-month period a total of 952 pregnant women were enlisted for the study, 702 were eligible out of which 660 (94.0%) agreed to participate; consisting of 225 subjects from Okposi ANC, 215 from Onicha ANC, and 220 from Uburu community ANC. Reasons for refusal to participate included fear of providing blood and lack of interest in the study. The mean age of the participants was 24.9 ± 6.1 years (range, 18-47years). Altogether 396 of the 660 participants of different age groups presented with varying degrees of anaemia during the study period thus providing an overall anaemia prevalence of 60%. The mean number of previous pregnancies was 4.7 ± 1.2 per woman (range, 1-12). The data on obstetric, demographic



and socio-economic characteristics associated with anaemia prevalence among the study population indicated that about 10% of the participants had no formal education and could neither read nor write, and only 24.3% proceeded beyond the first six years of primary school education (Table 1). A substantial proportion (56.0%) of the women were engaged in household chores, 40.0% were retail traders while 4.0% were employed by government or other corporate organizations. The prevalence of anaemia did not differ with age, occupation, education, but was significantly associated with previous number of pregnancies, gestation age and socio-economic status. Of the total anaemic subjects, 40.2%, 65.6% and 79.7% were in their first, second and third trimesters of pregnancy, respectively (Table 1). There was a highly significant association between gestational age and anaemia prevalence among the study subjects (p < 0.05) with prevalence increasing with advanced gestational age.

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1.5 g/dl in Onicha, 10.9 ± 1.6 g/dl in Uburu and 11.3 ± 1.4 g/dl in Okposi, although the between-community difference was not statistically significant (p>0.05). In the multivariate analysis, anaemia in pregnancy during the study period was significant and independently associated with advanced gestational age, multigravidae and low socio-economic status (Table 3).

4. DISCUSSION Our present study is of special significance as it represents the first attempt at providing baseline information associated with the obstetric, demographic and socioeconomic characteristics of pregnant women of rural south-western Ebonyi State, Nigeria. Bundy et al. [14] had estimated that up to 24 million women of child-bearing age in sub-Saharan Africa may become pregnant annually. This high pregnancy estimate is usually related to an increase in the susceptibility of pregnant women to different infections as pregnancy, with the associated gestational age, is a period of high hormonal activity which may exert immunosuppressive effects on the childbearing woman [15,16].

Anaemic women in Hb level of 10 g/dl recorded the highest prevalence of 34.4% followed by 15.2% for those in Hb level 9 g/dl while lowest prevalence (1.5%) was observed among anaemic women in the 13 g/dl category. The mean Hb level was 10.8 ± 1.7 g/dl (range, 5.1-13.4 The study showed that three-fifths (60.0%) of the study g/dl). The prevalence of mild (10 g/dl ≤ Hb < 11g/dl), population of pregnant women presented with varying moderate (7 g/dl ≤ Hb < 10 g/dl), and severe (Hb < 7 g/dl) degrees of anaemia during the study period. The high anaemia was 56.8% (n=225), 37.9% (n=150) and 5.3% anaemia prevalence is in agreement with data from other (n=21), respectively (Fig. 1). Morphological changes in developing countries [1] and also the mean percentage for the circulating erythrocytes were not observed in a African countries put at 61.0% [17]. The high prevalence significant proportion (76.0%) of the different categories could be attributed to several factors including iron and of anaemia. Over 90% (n = 359) of the total anaemic folic acid deficiencies arising from malnutrition and pregnant women had Hb levels below the WHO feeding consistently on root crops and cereals with low benchmark for pregnant women (11g/dl). The distribution iron contents. This nutritional pattern is especially of anaemia and Hb levels among the pregnant women dominant in the study rural area where socio-economic participants from the three study sites in southwestern standard is considerably low. Given the fact that Ebonyi State is shown in Table 2. Out of 396 anaemic substantial proportions (73.0%) of the anaemic pregnant women, 32.8% (n=130), 36.4% (n=144) and 30.8% women were of low socio-economic status, with majority (n=122) attended ANC at Okposi, Onicha and Uburu of them in the 18 – 34 years age category, socio-economic communities, respectively. Seventy six (76) anaemic status may also be a predictor of anaemia during pregnant women were in their first trimester, of which 29 pregnancy. In addition, short intervals between (38.2%) were from Onicha ANC, 22 (28.9%) from Uburu pregnancies among low socio-economic women may be ANC and 25 (32.9%) from Okposi ANC. Similarly, most contributory to maternal anaemia in pregnancy. In this of the anaemic women in their second (35.0%) and third study, anaemia prevalence increased with increasing (39.7%) trimesters of pregnancies were recorded in gestation period. Similar data for anaemia in pregnancy Onicha ANC than in either Okposi (33.1% and 31.7%) or have been reported in sub-Saharan Africa [18,19]. In these Uburu (31.9% and 28.6%), respectively. Generally, the regions, there is progressive collapse of weak reserves of trimester-specific mean prevalence of Hb levels showed iron and folic acid during pregnancy as a result of no significant difference in the Hb levels. The community increased demand by the foetus and haemodilution. mean of means Hb levels distribution varied from 10.3 ± Table 1 Obstetric, demographic and socioeconomic characteristics associated with prevalence of anaemia during pregnancy in southwestern Ebonyi State, Nigeria, 2012-2013 Anaemia Obstetric, demographic No of study pregnant and socioeconomic Unadjusted Prevalence women No (%) P-value characteristics Ratio Age (Years) 18-25 297 (45.0) 203 (68.4) 1.04 (0.98-1.11)b 0.23 26-34 251 (38.0) 137 (54.6) 1.00 35-44 99 (15.0) 54 (54.5) 1.03 (0.94-1.14) 0.56 ≥45 13 ( 2.0) 2 (15.4) 1.02 (0.92-1.15) 0.24



Gestation age First trimester 189 (28.6) Second trimester 392 (59.4) Third Trimester 79 (12.0) No. of pregnancies 1 132(20.0) 2-4 314 (47.6) 5-6 116 (17.6) ≥7 98 (14.8) Occupation Housewife 370 (56.0) Informal business 264 (40.0) Employee 26 ( 4.0) Education None 63 ( 9.5) Primary (1-6years) 437 (66.2) Secondary (≥7years) 160 (24.3) Socioeconomic status Low 277 (42.0) Middle 343 (52.0) High 40 ( 6.0) b Figures in parenthesis are the 95% confidence interval

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76 (40.2) 257 (65.6) 63 (79.7)

1.00 1.26 (1.14-1.41) 1.90 (1.20-1.49)

90 (68.2) 187 (59.6) 67 (57.8) 52 (53.1)

1.06 (0.97-1.1) 1.03 (0.93-1.12) 1.02 (0.92-1.13) 1.00

0.17 0.42 0.56

230 (62.2) 154 (58.3) 12 (46.2)

1.32 (1.07-1.62) 1.30 ( 1.07-1.61) 1.90 (1.02-3.65)